Thursday, November 29, 2018

US life expectancy falls again

I had planned to tackle a different topic today until I saw the front-page story announcing “U.S. Life Expectancy Falls Further.” The Centers for Disease Control (CDC) released data on Thursday showing that life expectancy in 2017 fell by a tenth of a year, to 78.6 years. While this may not sound like much, it is in stark contrast with what is happening in most of the developed world, where life expectancy is rising. The U.S. has lost three-tenths of a year since 2014, an astonishing reversal for a wealthy nation, and lags even further behind our peer countries. Life expectancy in Japan is 84.1 years and in Switzerland it is 83.7; these are the two OECD nations with the highest life expectancy. Of the 36 OECD nations, the U.S. ranks 29th. So much for the nonsensical claim that changing our current health care system would result in our losing our “best in the world” health care. Somehow “We’re number 29!” just does not have much ring to it, does it?
As I point out in Prescription for Bankruptcy, not all of a nation’s health is due to health care. One could make the argument that the health care system is actually less important than social factors in determining a country’s overall state of health. When John Snow stopped the Broad Street cholera epidemic in London a century and a half ago, he did it not by inventing a new medication but by removing the handle off the water pump that was the source of most of the local cholera. The dramatic fall in cardiac deaths in the U.S. in the past decades has owed less to medical intervention than to the very effective anti-smoking campaigns that have reduced cigarette smoking.
One of the factors behind our depressing fall in life expectancy has been the increased rate of suicide in the U.S. Around the world, increased urbanization and social stability have led to a dramatic 29% drop in suicides since 2000 (see: The Economist, Nov 24/2018), while in the U.S. the suicide rate is up 18%. Rates are highest among those who have suffered job loss and loss of social support, and are highest among those in the most rural areas. The ready availability of firearms means that when a suicidal impulse occurs – and it is by far most often an impulsive action rather than a carefully-planned decision – it is likely to be “successful.” Also playing a role is the opioid epidemic, and the increased availability of very potent opioids such as fentanyl. These deaths play an outsized role in our lower life expectancy because they occur in young adults.
To move up from the bottom of the heap, we need to reduce the easy access to guns, put more effort into fighting the opioid epidemic, and vastly improve our social support network. A $1 million spent on a new gene therapy may save one life. The same $1 million spent on suicide prevention could save hundreds.

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Wednesday, November 21, 2018

If you have a doctor you like and trust, stay with them - you will live longer!

Having been in practice in Framingham, Massachusetts, for over 35 years, I had quite a few elderly patients. One day when I was making hospital rounds, including seeing two patients over 90, a nurse smilingly said "you know, Dr. Hoffer, your patients just don't die!" I responded jokingly that I made them all sign a contract not to die until I permitted it, and thought no more of it. However, as we move away from having lifetime relationships with our physicians, and as medical care becomes more and more fragmented, it turns out we are losing more than a Norman Rockwell moment. Data now very strongly supports the importance of continuity of care in optimal health outcomes.
A study done in South Korea and published in the Annals of Family Medicine (Nov/Dec 2014) looked at a cohort of over 47,000 patients with newly diagnosed hypertension, diabetes and high cholesterol. They followed these patients for five years. They used standard methods of measuring continuity of care and compared outcomes with greater or less continuity. Those with lower indices of continuity of care had 12% higher death rates, 57% more heart attacks and 44% more strokes than those with higher continuity scores. The results make intuitive sense to me, because all of the conditions they studied are known to respond to medication, and both high blood pressure and high cholesterol have no symptoms and it is well-known that many patients stop taking their prescribed medicines. Having a trusting relationship with your doctor, and regular follow-up, makes it more likely you will follow the plan of care prescribed.
Just this year, a very large "meta-analysis" published in BMJ Open (Pereira Gray DJ et al) looked at 22 studies of the impact of continuity of care on health outcomes. They found very strong association of increased continuity of care with decreased mortality.
Not only is life extended, but costs are lower! A study by Andrew Bazemore at al published in the November 2018 issue of the Annals of Family Medicine looked at a sample of 1.45 million Medicare beneficiaries cared for by 6,551 primary care physicians. Comparing patients in the highest and lowest quintiles of continuity scores, they found that odds of hospitalization were 16% lower with good continuity of care and costs per patient were 14% lower (presumably reflecting less hospitalization).

As we look at needed reforms in our system, it is critical that this data be kept in mind.

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Sunday, November 18, 2018

Lies, damn lies and statistics

The Wall Street Journal published an Op-ed piece on November 12 titled "The False Promise of 'Medicare for All'" by Scott Atlas of the Hoover Institution, promising death and financial ruin should we adopt this approach. I believe that Atlas cherry picked his facts and reached the wrong conclusion. He starts his piece with the frightening thought that Medicare for all would cost $32 trillion over the next decade, an estimate that The Tax Policy Center had previously published. What he fails to mention is that under our current "non-system," the cost projection is much worse. In 2017, US health care expenditures were $3.5 trillion - about twice as much per capita as in comparable Western democracies. If we assume a (very) conservative inflation factor of 5%, the projected cost over the next decade would be over $46 trillion - thus making Medicare for All a veritable bargain! He claims that nationalized programs have failed to provide high quality care compared to the US system, based on largely anecdotal data. As to quality, it is clearly true that wait times in the US are shorter than in most other countries, but what matters more than wait times is the health outcomes. The average life expectancy in the United States is 78.6, while it is over 80 in at least 29 other countries, including Japan and most of Europe. Maternal death rates in the US are dramatically worse than in other OECD nations. Rates of death per 100,000 live births range from 6.4 in Japan to 9 in Germany, while in the US it is 26.4. Our death rates for infants and children are much higher than are those in other OECD nations. A very revealing study found that when looking at treatment of patients with advanced colon cancer treated in neighboring Washington state and the Canadian province of British Columbia, the cost of care in Canada was half that in the United States and that the Canadian patients lived longer! For more details, see my book Prescription for Bankruptcy.

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Tuesday, November 13, 2018

Guns DO kill people

The National Rifle Association recently condemned doctors who are against gun violence, telling us to "stay in our own lane," and complaining we had not checked with outside experts (i.e., them). Last that I heard, reducing preventable deaths was exactly the main lane for doctors. Quite appropriately, this stance has led to a major reaction by doctors, one of whom, a trauma surgeon, posted a picture of herself and the operating team with a young patient who had just succumbed to his bullet wounds despite their attempts. The Centers for Disease Control and Prevention (CDC) recently released a report on firearm homicides and suicides, in MMWR 67(44):1233-7, dated November 9, 2018. They, in an understated way, said that "firearm homicides and suicides represent a continuing public health concern in the United States." During 2015-2016, the US experienced 27,394 homicides, including 3224 among persons 10-19, using guns. In the same period there were 44,955 firearm suicides, including 2,118 among youngsters 10-19. We are so much worse than any other Western democracy that comparisons are meaningless. As I point out in my new book, Prescription for Bankruptcy, people can attempt suicide by many means, but no other means is nearly as "successful" as suicide by gun. Many measures have been proven successful, and none of these would infringe on the legitimate use of firearms by hunters. If every state in the country had similar laws to those in Massachusetts, and a similar death rate from guns, tens of thousands of American lives would be saved. We supposedly live in a country in which the majority rules, respecting the rights of minorities. A clear majority of Americans want better gun control. We MUST stand up to the NRA and tell our elected officials they will not be re-elected if they do not grow spines.

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Monday, November 12, 2018

Don't throw out out those old pills!

As I mention in my book, Prescription for Bankruptcy, one of the many ways big pharma soaks the consumer is by putting arbitrary expiration dates on their pill bottles. Nursing homes and hospitals regularly throw out perfectly good medicines because they are "outdated" and cannot be given to patients. Many patients do the same, trusting the dates stamped on the bottles. This behavior is despite multiple studies both old and new showing that pills are perfectly good well past the date on the bottle. I have always tried to advise my patients to use up all of the pills unless they were obviously crumbling, but I had made an exception for nitroglycerine pills. These are used to treat angina attacks (temporary heart pain brought on by exertion), and are meant to dissolve under the tongue. This compound seemed unstable enough that I advised my patients to store their reserve supply in the fridge and replace the pills every 3-6 months. Well, it turns out I was mistaken, and even this seemingly unstable compound lasts a lot longer than I thought. A study soon to be published in The American Journal of Cardiology looked at nitroglycerine tablets carried in pocket or purse. The 25-count bottles carried in a pocket maintained their potency for 2 years, while those carried in a purse were good beyond 2 years whether in 25- or 100-count bottles. Only the 100-count bottles carried in a pocket fell below acceptable limits at 12 months.

Sunday, November 11, 2018

Women should not die from childbirth in the United States!

Despite spending dramatically more on health care than any other county in the world, the US does not lead the world in health outcomes. Most sadly, the rate of maternal mortality in this country is triple that of other western democracies. As documented in my book, Prescription for Bankruptcy, countries such as Canada, Germany and France in 2015 had maternal mortality rates ranging from 6 to 9/100,000 births while in the US over 26 women died per 100,000 births. The maternal death rate is particularly bad for African-American women. We could do better if we applied well-known principles. As outlined in a position paper in the New England Journal of Medicine dated 11/1/18, there are several published bundles of best practices that would drop the maternal death rate dramatically if adopted by all hospitals. Since many of the pregnancy-related deaths occur after delivery, good follow-up care is essential. Unfortunately the US is one of the few Western democracies that does not mandate paid maternity leave, and as a result, only one postpartum visit is usually scheduled, and half of these visits are skipped. Could we do better? Yes. Will we? Time will tell. Read my book. Put pressure on our elected officials.

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Saturday, November 10, 2018

Are the foxes watching the henhouse?

Increasingly, doctors are expected to follow published guidelines on how to evaluate and treat patients. In many cases, payment is predicated on following these guidelines and in other circumstances, payment for "quality" is geared to compliance with them. There are now literally thousands of such guidelines, often conflicting with each other.
Many professional organizations convene panels of "experts" to issue guidelines on how doctors should evaluate and treat patients. These have the aura of being the last word on the subject, and are used both to guide the practice patterns of individual physicians and often what insurance companies will pay for. It would be wonderful to believe that the panel experts were both knowledgeable and unbiased, but growing evidence says that the panel members all too often have serious conflicts of interest. Some of these are inherent to being in the specialty; if you are a diabetes expert, it is wonderful to lower the threshold at which diabetes is diagnosed and instantly have millions of more diabetics needing your care. Others are financial. Two recent studies published online on JAMA Internal Medicine (on October 29, 2018) looked at this. One showed that over half of the authors of clinical practice guidelines in the field of gastroenterology had financial ties to industry, and that many of these ties were not publicly revealed. Another looked at the authors of guidelines related to very high-cost medications. They identified 18 sets of guidelines covering the use of ten very high cost medications. Out of 160 US-based physicians, half declared receipt of payments from industry and an additional 25% HAD received such payments but not disclosed them. The process of developing practice guidelines needs a hard look and revision to be sure these are based on what is truly best and not what is simply good and also expensive. Guidelines should be developed by neutral experts, and should include patients, primary care providers and experts on statistics as well as specialist with expertise in the field. Read more about this in my new book, Prescription for Bankruptcy.

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Friday, November 9, 2018

We MUST keep coverage for pre-existing conditions

Despite the Republican party's efforts to "repeal and replace" the Affordable Care Act, "Obama Care" is still with us. Most of the American public have come to realize that a crucial safety feature of the ACA is its mandate that all health insurers cover pre-existing conditions, and that repealing it would take us back to the dark ages when you could find yourself without insurance when you needed it. How widespread are "pre-existing conditions?" An analysis by Avalere health looked at the subject in depth. They found that of the 204 million people who were not in Medicare or Medicaid, fully half: 102,000,000, had one or more so-called pre-existing conditions, including hypertension, diabetes, chronic lung disease, cancer, mental health problems and others. A December 2018 report by CNN also found that roughly 50% of all Americans had some condition or illness that would be considered a pre-existing condition by health insurers, and that a whopping 86% of Americans aged 55 to 64 have one or more such conditions.
In descending order of frequency, the conditions that would not be covered were: acne (>50 million), anxiety (39 million), diabetes (30 million), asthma (25 million), sleep apnea (25 million), depression (20 million), extreme obesity (18 million), chronic lung disease (16 million), coronary disease (16 million) and cancer (15 million)
Since most employer-based health insurance covers families, this means that almost every person is potentially subject to this problem. In the bad old days, you could find that if you switched jobs, your new employer's health plan would not cover you for any illnesses you had. Your choices were then to remain as an indentured servant to your current plan or switch jobs and keep your fingers crossed. However we go, whether towards Single Payer or by improving our current system, maintaining coverage for all medical problems must be a bedrock principle. Read more in my book, Prescription for Bankruptcy.

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Thursday, November 8, 2018

Don't rely on Dr. Google

I have a wonderful cartoon on my desk that is appreciated these days by most doctors. A patient is sitting on an exam table, saying to the doctor: "I already diagnosed myself on the internet. I am just here for a second opinion." While the internet is a wonderful source of ideas, it is like an oriental bazaar, with trash and treasure intermingled and often indistinguishable. Nineteenth century America had travelling snake oil salesmen and 21st century America has the Internet. The biggest problem with using search engines to suggest what you have and what to do about it, which most people forget or never knew, is that placement on the page of "hits" is NOT by goodness of fit. Sites pay directly for high placement, and clever consultants teach you how to get high placement for your site by fine-tuning the descriptors. The best answer to your question may be half way down the second page, and you may never look that far. I tried to convince my patients to always start at the NIH PubMed site, which has a wealth of reliable, vetted and unbiased material. If you do not find what you want there, the next place to look is on sites maintained by large hospital systems such as the Mayo Clinic, that offer validated facts and opinions. The commonly used patient symptom checkers are used by millions, and can be helpful but can be very wrong. Part of the problem is their limited databases. Researchers from McMaster University's ophthalmology department entered 42 scenarios of patients with known eye diseases into the WebMD Symptom Checker and found that while the correct diagnosis did appear in the top three 40% of the time, it was not listed at all 43% of the time! Someone has to pay for these "free" services, and it is usually pharmaceutical companies that want you to use their products. The internet symptom checkers thus give priority to conditions for which there are linked ads. is OK to start with "Dr. Google," but caveat emptor: let the buyer beware. For more see my new book, Prescription for Bankruptcy.

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Wednesday, November 7, 2018

The $48,000 allergy test

A recent posting on Kaiser Health News epitomized much of what is wrong with health care in today's America. An English professor in the California state university system went to Stanford University's outpatient clinic for help with a rash that she thought might be due to a cream she had been prescribed. She had 119 tiny plastic containers taped to her back and ultimately learned that she was allergic to a variety of things, including the ingredient in her cream. All well and good until she saw that Stanford had billed her insurance company for $48,329! This included $848 for the time she spent with the doctor and $399 for each of the 119 small samples taped to her skin. The "usual and customary" charge in the San Francisco Bay area for this is $35 per sample. Why so much? Stanford, as a prestigious institution, has a lot of clout when it comes to negotiating with insurers. They know that many companies want access to "the best" and so drive a harder bargain than smaller hospitals. The insurer paid Stanford at their negotiated rate of $11,376 - still 3-4 times what they would have paid an allergist in private practice for the same service. We need single payer, where the payer and not the provider are in the driver's seat. Read more in my book, Prescription for Bankruptcy.

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